Provider Demographics
NPI:1689839813
Name:TUCKER, JASON DAVID (MD)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:DAVID
Last Name:TUCKER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:12312 COPPER WAY
Mailing Address - Street 2:SUITE 200
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28277-3386
Mailing Address - Country:US
Mailing Address - Phone:980-859-2340
Mailing Address - Fax:844-830-8115
Practice Address - Street 1:12312 COPPER WAY
Practice Address - Street 2:SUITE 200
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28277-3386
Practice Address - Country:US
Practice Address - Phone:980-859-2340
Practice Address - Fax:844-830-8115
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-28
Last Update Date:2016-11-03
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
VA0101249850208100000X
NC01109213ES0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0000XPodiatric Medicine & Surgery Service ProvidersPodiatristSports Medicine
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation